Editor's blog Monday 25 October 2010: Machiavelli and Lansley - fear, power and the innovator's dilemma

There is only one essential book about management: The Prince, by Niccolo Machiavelli. That exiled-from-court Renaissance Mandelson sought to curry his way back into favour with the reigning Lorenzo de Medici by dedicating to him a book on how a prince should run his principality.

Machiavelli distinguished between established, hereditary principalities; and those newly-conquered. He also differentiated between well-used cruelty and badly-used cruelty.

One of his best-known dicta is about revolutionary change. Machiavelli set out the innovator's dilemma: that “the innovator makes enemies of all those who prospered under the old order, and only lukewarm support is forthcoming from those who would prosper under the new order. Their support is lukewarm partly from fear of their adversaries, who have the existing laws on their side, and partly because men are generally incredulous, never really trusting new things unless they have tested them by experience”.

So. Liberatin' Andrew Lansley, Secretary Of State, is an innovator on a rare scale for the NHS. His response to NHS management as we know it is to want to abolish it. He has inherited the established principality of the NHS, but wants essentially to destroy it and so create a new system - "the largest social enterprise in the world".

The Italian job
The lessons of Machiavelli look highly relevant to Liberatin' Lansley's situation.

What can Mr L learn from Mr M?

Machiavelli warned that to keep his own team onside, a leader must have a means of force to compel his followers to remain faithful to his vision for change.

This one is, quite frankly, a problem for Mr Lansley. He has told the staff of SHAs and PCTs that their jobs are going, and that the Independent Commissioning Board (and its regional offices) will be "light and lean". The void of detail on GP commissioning consortia (number, size, scope, governance, management budget) will not be heightening their confidence that there is a job for them in Mr L's brave new world.

And these are the people who are desperately needed to prevent the current system overheating under financial pressure. Let alone to make the transition to the new system.

Oops.

In place of fear
On popular opinion of the leader, Machiavelli advised that when it comes to choosing between being loved and being feared, "one would like to be both the one and the other; but because it is difficult to combine them, it is far safer to be feared than loved if you cannot be both".

Mmmm. The management culture of the NHS is, to put it mildly, top-down to the point of near-Stalinism.

Legally, financially and politically, accountability flows up the system to the Secretary of State for Health via the chief executive of the NHS. Power - and fear - flow down from the Secretary of State for Health via the chief executive of the NHS.

Very Bad Things have happened because of the old-money power hierarchy of the NHS.

In the current, old-money hierarchy, there are two centres of power: Secretary of State for Health Andrew Lansley CBE and NHS chief executive Sir David Nicholson.

Mr Lansley's reforms are all about changing this. His solution is to create two new centres of power.

The first is the world's most finanicially influential quango: the new Independent Commissioning Board - an arms' length, semi-independent authority which will decide what the NHS will commission and fund.

Alongside it, he will create Super-Monitor - the FT regulator will be the new system's economic regulator, which will also be concerned with competition and market issues.

In the new money, commissioning consortia and providers will be fearing the independent National Commissioning Board (the Secretary of State for Health, in the old money) and Super-Monitor (the chief executive of the NHS in the old money).

(By the way, can you see any sign of a democratic deficit emerging in this change?)

The residual function of the Secretary of State for Health will be threefold. His or her job will be to argue for money with the Treasury; to 'do public health' in a mysterious manner; and to interfere in the system where required. (You will recall that the coalition agreement's "free from political interference" became "free from day-to-day political interference" by the time of Mr Lansley's NHS Confederation speech. It won't be daily; but it certainly won't be never. So perhaps we should get used to calling it the generally-indepnendent NCB - GIN, for short.)

It would be nice to know whether the Secretary of State for Health will also have the ability to appoint or dismiss the chair and chief executive of the new GIN quango and Super-Monitor (real power, as it is usually known). But such information is of course the devil's domain of detail. And we are not getting that.

The Secretary of State for Health's job will not be to be feared.

He or she is, you could argue, no longer the ruler in the new system. And it is true that the new system will aim to insulate the noise of a  dropped bedpan from his or her ears, and the top-down interference that ensues.

The problem arises because in the new system, the Secretary of State for Health is the person with an electoral mandate.

If he or she is not feared, but can appoint or dismiss the two new centres of power and fear in the brave new world, then we will have yet another big problem.

Which will create a fascinating and ugly range of new dysfunctional behaviours.